Ruminations by a non-academic general surgeon from the heart of the rust belt.

Monday, June 6, 2011

More Checklist Consequences

One of the SCIP protocols involves removing foley catheters post op within 48 hours to reduce hospital acquired urinary tract infections. UTI's acquired during a hospitalization, of course, are a "never event" and hospitals are loath to subject themselves to reimbursement penalties therein. One way to control this is to program the Electronic Medical Record (EMR) for Physician Order Entry (POE) such that all foley catheters are automatically removed by post op day #2 no matter if the surgeon wants it or not. By making foley removal the default pathway, you improve foley removal rates and, presumably, lower rates of acquired UTI's. The doctor is removed from the decision-making process altogether.

My partner operated on someone with an incarcerated hernia not too long ago. The patient was an older guy and he had to perform a limited bowel resection. A foley was placed prior to incision. The guy had a history of severe BPH and it was a struggle to get the catheter in. In his post-op orders he checked the standard box on the POE for Foley care (usually a bag to free gravity).

Unbeknownst to him, the "Foley care" order contained a drop-down box (accessible by clicking a separate tab) mandating that the catheter was to be removed on post-op day #2. In the evening of post op day #2, my partner received a phone call from the nurse---your patient hasn't been able to void since the catheter came out.

"Why is it out? I never wrote that. The guy has a prostate the size of a tennis ball."
"I don't know doctor. But he's having a lot of pain. The lasix you wrote for worked though. The bladder scanner says he's retained 700cc of urine."

And of course the house officer couldn't get the Foley in. Urology had to be consulted, urgently. The guy ended up getting another catheter placed, this time without the benefit of deep anesthesia. According to one of the nurses on that night, it took about 30 minutes of penis stabbing to get it in. But at least the hospital's SCIP data will look good.

6 comments:

just some doofus
said...

That is a real shame and clearly bad for patient care. However, this goes to show the need to be vigilant with EMRs for this sort of hidden hazard. I wonder if there was a way to override this in the computer system that you have at the time the order was placed.

Back when I was in Medical School, don't wanta say exactly when, but "Thriller" was still in the top 10, Bo Jackson in the SEC, and Bill Buckner was known as a slick fielding-Good Hitting First Baseman...Residents would often write an order for a "Bedtime Snack", so that the patient could get a nourishing ice cream samwich/cone/popsicle, otherwhise they'd have to go without food from 6pm to 6am...One residents writing was particularly bad, and a nurse called him questioning his order for a "Bigtime Snake"

Interesting situation. From a checklist standpoint I would say that the default should be to remove a foley , but the order should not be 'hidden', but all orders that are being placed should be visible. From an EHR perspective, this should push for stronger clinical decision support. Specifically the updated problem list (a challenge in itself) should include the BPH and then prompt the physician to to verify the removal of foley at 24 hours in a pt with BPH. As we inevitably move towards more cookbook medicine we need to be more cognizant of these '1%' events-things that occur rarely, but in aggregate have significant effects. I see it similar to the issues with vaccination. There is an exceedingly small number of patients with true allergies to vaccienes, but the devestating consequences need to be addressed rather than eliminate vaccines altogether.

I agree your case is a shame and did not need to happen. This isn't so much a checklist problem as it is a system problem. You guys need to regain control (if you ever had it) of the process of medical care in your hospital.

In my hospital, we can extend the time the Foley catheter is in place by simply writing a note that the catheter is necessary. It can be frustrating because even an oliguric patient in shock on vasoactive drugs must have such a note written. Common sense does not prevail and it's easy to forget to do it.

Don't yield to the bureaucrats. Get the policy changed to allow for appropriate care.

This is one reason why administration forces the automatic over-ride of MD EMR orders. Sorry the link is so long, but I wanted to navagate to some information so that you could scroll down. BTW, random facilities, just for example purposes.

-SCRN

Once at this link, click "process of care measures" tab on the left in the second grouping down...

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